Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue. American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of April 2002. This issue has been approved for up to 4.5 Prescribed credit hours. Credit may be claimed for one year from the date of this issue.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 4.5 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

NOTE: The full text of AFP is available online (www.aafp.org/afp), including each issue’s Clinical Quiz. The table of contents for each online issue will link you to the Clinical Quiz. Just follow the online directions to take the quiz and, if you’re an AAFP member, you can submit your answers for CME credit.

Good communication is the bridge that spans the gap between the mind of the doctor and the patient. In this paper, the scope of the term communication skills has been broadened to include the knowledge, attitude and skills that enable a doctor to know and respond to the totality of the disease process as it affects the body and mind of the patient.

Communication is effective only when it is a two way process. Good communication draws upon knowledge of psychological, cultural, social, educational and economic influences upon the patient and disease. It requires that intellect and emotion be yoked together in the service of the alleviation of suffering and the promotion of health.

At the heart of the practice of medicine is a dynamic process seeking the best fit between the patient’s needs, the physician’s perception of the patient’s needs and what the physician has to offer. Fine tuning of this process requires knowledge of the patient’s values, attitudes and beliefs and therefore the social, cultural, religious and economic milieu of the patient. The ability to respond effectively is determined by the extent to which the doctor understands the working of the human mind, can discriminate between the subjective and objective aspects of human experience and can read between the lines of verbal expression.

The bed rock of good communication is the ability to ‘feel with’ the distress caused by the disease process. Once this ability is in place the trainee becomes motivated to fine tune communication and re-orient service towards a more patient centered approach. In the absence of the ‘feeling’ element , the ‘knowledge’ element of communication may never translate into action.

Special challenges in communication

While some basic rules of communication apply across cultures and continents, communication must be sensitive to individual variations. Culture, religion, social systems, and economic structure are some of the influences that determine the manifestations of disease and expressions of distress.

Socio-cultural variations

The economically deprived patient with little or no formal education does not come to the consultation alone. He is accompanied by his family or even members of his village unrelated to him. He is also accompanied by an invisible host of authority figures who influence his beliefs, attributions, preferences, values and hopes. The doctor ignores these at his own peril.

Technology will play an ever-increasing role in the medical arena as physicians prepare to enter the 21st century. To compete in that arena and to provide high-quality comprehensive, continuous, and coordinated care to patients, physicians must be able to process large and varied amounts of information. Computerization of the medical record is the best way in which the physician can more readily manage and retrieve important information about patients.

The technology to computerize the complete medical record is available and increasingly accessible and affordable. (1) The cost of mass storage, which has heretofore been a major limiting factor in medical record computerization, is decreasing. Two recent developments–the compact disc-read only memory (CD-ROM) and the write once read many optical disc (WORM)–offer gigabyte mass storage capability at affordable prices. (2,3) A growing number of computerized medical record systems have been tried and tested in the ambulatory care setting and are available for purchase. (1,4) The Computer-Stored Ambulatory Record system (COSTAR) was developed by the Laboratory of Computer Science at Massachusetts General Hospital and is the most widely disseminated system of its type. (1) Other available systems include the following:

1. The Medical Record (TMR), developed at Duke University Medical Center (5)

2. The Regenstrief Medical Information System (RMIS), developed at Indiana University Medical Center (6)

3. The Summary Time-Oriented Record (STOR), developed at the University of California Medical Center, San Francisco (7)

4. THERESA, a computerized medical record and decision support system developed by Grady Memorial Hospital in Atlanta (8)

Although the technology is available, (2) a completely paperless electronic medical record (to include electrocardiograms, correspondence, radiographic images, etc) is not necessary or practical at this time. But the electronic paperless office is a future reality, and physicians can and should begin moving their practices in that direction. Currently components of the medical record that can be computerized include reason for encounter, symptoms, signs, diagnostic and therapeutic procedures, test results, diagnoses or problems, and prescribed therapies.

* OBJECTIVES To determine (a) the respondents’ perceptions of 4 unclear or conflicting cancer screening guidelines: prostate-specific antigen (PSA) for men over 50, mammography for women 40-49, colorectal screening by fecal occult blood testing (FOBT), and colonoscopy for patients over 40; and (b) the influence of various factors on the decision to order these tests.

* STUDY DESIGN National Canadian mail survey of randomly selected family physicians.

* POPULATION Family physicians in active practice (n=565) selected from rural and urban family medicine sites in 5 provinces representing the main regions in Canada.

* OUTCOME MEASURED Agreement with guideline statements, and decision to order screening test in 6 clinical vignettes.

* RESULTS Of 565 surveys mailed, 351 (62.1%) were returned. Most respondents agreed with the Canadian Task Force recommendations, and most believed that various guidelines for 3 of the 4 screens were conflicting (PSA 86.6%; mammography 67.5%; FOBT 62.4%). Patient anxiety about cancer, patient expectations of being tested, and a positive family history of cancer increased the odds that the 4 tests would be ordered. A good quality patient-MD relationship decreased the odds of ordering a mammogram. Screening decisions were also significantly influenced by the respondents’ beliefs about whether screening was recommended and whether screening could cause more harm than good. A physician’s sensitivity to his or her colleagues’ practice influenced screening decision, s regarding PSA and mammography.

* CONCLUSIONS These results suggest a conceptual framework for understanding the determinants of screening behavior when guidelines are unclear or conflicting.

* OBJECTIVES The goal of this study was to develop a psychometric instrument that classified physicians’ response styles to new” information as seekers, receptives, traditionalists, or pragmatists. This classification was based on specific combinations of 3 scales: (a) belief in evidence vs experience as the basis of knowledge, (b) willingness to diverge front common or previous practice, and (c) sensitivity to pragmatic concerns of practice. The instrument will help focus efforts to change practice more accurately.

* STUDY DESIGN This was a cross-sectional study of physician responses to a psychometric instrument. Paper-and-pencil survey forms were distributed to 3 waves of physicians, with revision for improved internal consistency at each iteration.

* POPULATION Participants were 1393 primary care physicians at continuing education events in the Midwest or at primary care clinic sites in the Veterans’ Health Administration system.

* OUTCOMES MEASURED Internal consistency was measured by factor analysis with orthogonal rotation and Cronbach’s alpha.

* RESULTS A total of 1287 usable instruments were returned (106, 1120, and 61 in the 3 iterations, respectively), representing approximately three fourths of distributed forms. Final scale internal consistencies were a = 0.79, b = 0.74, and c = 0.68. The patterns of scores on the 3 scales were consistent with the predictions of the theoretical scheme of physician types. The “seeker” type was the rarest, at fewer than 3%.

* CONCLUSIONS It is possible to reliably classify physicians into categories that a theoretical framework predicts will respond differently to different interventions for implementing guidelines and translating research findings into practice. The next step is to demonstrate that the classification predicts physician practice behavior.

* KEYWORDS Patterns, physician’s practice; education, medical, continuing; practice guidelines; decision making; psychometric instruments. (J Fam Pract 2002; 51:938-942)

KEY POINTS FOR CLINICIANS

* One size probably does not fit all when bringing physicians new information that might change their practice.

Physicians differ measurably in what they consider credible sources of information, the weight they assign to practical concerns, and their willingness to diverge from group norms in practice.

One of the benefits of hosting a visiting professor from England has been access to the British Medical Journal, and perhaps less esteemed but equally fascinating publications like GP. This tabloid, similar to FP News, highlights the striking similarities between our practices–once you get beyond the discussion of “list sizes,” the NHS (National Health Service), and of course, the term “GP” itself.

There are calls for GPs to ban together to fight kidney disease, obesity, and hypertension, to provide mammography on request, and to more effectively treat atrial fibrillation. Judged by my rigorous scientific sampling over tea and scones (well, maybe it was a Starbucks and a bagel) the clinical issues are immediately recognizable: screening for occult problems, effectively managing chronic disease, improving quality of care.

But what about the social and economic fronts? There are debates about maintenance of certification and “revalidation,” struggles to reduce hospitalization and rein in costs, and pharmaceutical advertising galore. Editorials reflect on whether physicians should be salaried, the demise of 24-hour responsibility of physicians, the influx of nurse practitioners–I could lift the copy verbatim for JFP. Underlying these discussions are debates about financing healthcare, workforce composition, and the eroding lifestyle and incentives to GPs.

As I get to know my new GP colleague, it is clear our hopes, struggles, and challenges are quite similar. Although, I do admit to wistfully dreaming about the “paper-light practice with no out-of-hours or weekend work, with 10,000 patients all very well trained.”

* BACKGROUND Ineffective management of laboratory test results can result in suboptimal care and malpractice liability. However, there is little information available on how to do this important task properly in primary care settings.

* METHODS We used a questionnaire guided by a literature review to identify a conceptual model, current practices, and clinicians who reported having an effective method for at least one of 4 steps in the process of managing laboratory test results. Clinicians with differing methods were selected for each of the steps. Practice audits and patient surveys were used to determine actual performance. On the basis of these audits, we constructed a unified best method and conducted time-motion studies to determine its cost.

* RESULTS After auditing only 4 practices we were able to identify effective methods for 3 of the 4 steps involved in the management of laboratory test results. The unified best method costs approximately $5.19 per set of tests for an individual patient.

* CONCLUSIONS By identifying effective practices within a family practice research network, an effective method was identified for 3 of the 4 steps involved in the management of laboratory test results in primary care settings.

* KEY WORDS Laboratories; primary health care; communication; practice management, medical.
Failure to notify patients of abnormal laboratory test results or to ensure appropriate follow-up can result in inferior patient care and potential malpractice liability.[1-5] Failure to document physician review and communication of test results to patients can make defense of a malpractice claim more difficult. Our review of the English-language literature identified only a few studies related to the management and reporting of laboratory test results in primary care.

In two U.S. studies about medical errors in 2000 and 2001, family physicians offered their ideas on how to prevent, avoid, or remedy the five most often reported medical errors. Almost all reports (94 percent) included at least one idea on how to overcome the reported error. These ideas ranged from “do not make errors” (34 percent of all solutions offered to these five error types) to more thoughtfully proposed solutions relating to improved communication mechanisms (30 percent) and ways to provide care differently (26 percent). More education (7 percent) and more resources such as time (2 percent) were other prevention ideas.

Of 416 error reports made by U.S. family physicians in two medical error studies in 2000 and 2001, 151 (36 percent) were about the most commonly reported errors involving the processes of ordering medications, implementing laboratory investigations, filing forms and maintaining patient records, implementing medication orders, and responding to abnormal laboratory test results.

Although identifying medical errors is an important first step in making primary care safer for patients, the major challenge is in finding ways to avoid them. When asked for their ideas on how to overcome the most common medical errors they reported, family physicians offered 228 distinct solutions, categorized in the accompanying table.

In 2000 and 2001, before patient safety was widely discussed in primary care settings, one third of family physicians’ solutions for overcoming medical error were not very helpful–doing the same thing, but better. The practicing environment may make it difficult for physicians to think in terms of systems or to imagine alternatives to their immediate realities. Surprisingly, only a small minority of the other, more practical solutions for overcoming medical errors in primary care required additional resources, and these resources were almost always time-related rather than monetary. Specific changes such as stopping the use of carbon copy prescription forms, doing urgent laboratory tests in the office, and using flagging systems to draw attention to information needing action were all practical suggestions for alleviating these common errors. Various double-checking systems also were favored. In searching for solutions to medical errors, asking those involved in providing care for their ideas may be a rewarding strategy.

Medical and technological advances in abortion care, including the introduction of mifepristone and the refinement of uterine aspiration techniques, have enabled earlier and simpler termination of unwanted pregnancy. These technologies are well suited for use by a wide range of health care providers in various settings. Expanding the number of providers offering early abortion care is particularly important in rural and underserved areas in the United States, where the number of abortion providers has been declining dramatically. From 1996 to 2000, the number of recognized abortion providers in California decreased by 19%; currently only 400 providers serve 7.5 million women of reproductive age in the state. (1)

In the United States, nonphysician clinicians, including advanced practice clinicians, are playing increasingly important roles as providers of health care. From 1987 to 1997, the proportion of patients who saw a nonphysician clinician increased from 31% to 36%. (2) Advanced practice clinicians-including nurse practitioners, physician assistants and certified nurse-midwives–have been shown to competently perform complex medical procedures and provide high-quality care. (3) Several advocacy and professional organizations have recognized advanced practice clinicians as technically qualified and appropriate providers of abortion care. (4) During their clinical training, advanced practice clinicians specializing in women’s health learn several related and equally complex skills, including how to date pregnancies by measuring uterine size and using ultrasonography, insert IUDs, perform intrauterine biopsies, suture simple lacerations and repair episiotomies. Although some states have laws that limit abortion care to physicians, advanced practice clinicians may assist physicians by providing counseling, taking medical histories, performing physical examinations (including to confirm and date a pregnancy) and managing side effects.

Edward Langston, M.D., Lafayette, Ind., was recently elected to a seat on the American Medical Association (AMA) Board of Trustees. Dr. Langston, who was nominated by the AAFP, is a past chair of the AMA Specialty and Service Society and has been a member of the AMA Council on Medical Education since 1997. He served on the AAFP Board of Directors from 1991 to 1993 and was Board vice president in 1994. AAFP member J. Edward Hill, M.D., Tupelo, Miss., was re-elected to the AMA Board of Trustees. Dr. Hill has been a member of the AMA board since 1996 and is the immediate past chair. Family physician Ann Jobe, M.D., M.S.N., Macon, Ga., was named chair-elect of the AMA Section on Medical Schools, and David Barbe, M.D., a family physician in Mountain Grove, Mo., was chosen to serve on the AMA Council on Medical Service.